Tui Dissertation Defense Abbrv   Hales (Linkedin)
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Tui Dissertation Defense Abbrv Hales (Linkedin)

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An Abbreviated version of the defense presentation presented to the PhD committee of TUI University

An Abbreviated version of the defense presentation presented to the PhD committee of TUI University

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    Tui Dissertation Defense Abbrv   Hales (Linkedin) Tui Dissertation Defense Abbrv Hales (Linkedin) Presentation Transcript

    • Standard Medicare Drug Benefit, 2006 $386 average annual premium*** $250 Deductible $2,250 in Total Drug Costs* $5,100 in Total Drug Costs** 25% 5% $2,850 Gap: Beneficiary Pays 100% Medicare Pays 75% Medicare Pays 95% No Coverage (the “doughnut hole”) Catastrophic Coverage Partial Coverage up to Limit Beneficiary Out-of-Pocket Spending *Equivalent to $750 in out-of-pocket spending. **Equivalent to $3,600 in out-of-pocket spending. ***Based on $32.20 national average monthly beneficiary premium (CMS, 8/05). SOURCE: KFF analysis of standard drug benefit described in Medicare Modernization Act of 2003. www.kaisered.org
    • The “Doughnut Hole” National Committee to Preserve Social Security and Medicare. http://www.ncpssm.org/news/archive/update_partd_2008/
    • Problem Statement
      • The doughnut hole may influence prescription fulfillments since low co-payments will be replaced with high out-of-pocket costs.
      • Medicare Part D members’ prescription fulfillment decisions, defined as filling, delaying, switching, or completely stopping the fulfillment of a prescription, might be affected by a sudden benefit design change (100 percent cash prescription responsibility) as defined as the doughnut hole.
      • Studies need to be conducted to determine whether the doughnut hole affects prescription decisions of Medicare Part D enrollees .
    • Study Aim and Purpose
      • The purpose of the study is to determine whether the doughnut hole has any effect on prescription medication utilization as measured by filling, delaying, switching or cessation of the purchase of a prescription medication .
      • The specific aims of the study are as follows:
        • 1.    The first aim of the study is to determine the effect of the doughnut hole on the filling of prescription medication.
        • 2.    The second aim of the study is to determine the effect of the doughnut hole on delaying the purchase of prescription medication.
        • 3.    The third aim of the study is to determine the effect of the doughnut hole on switching of prescription medication.
        • 4.    The fourth aim is to determine the effect of the doughnut hole on prescription medication cessation.
        • 5.    The fifth aim is to determine the effect of utilization against the confounding effects of the following covariates: age, gender, number and type of medication.
    • Research Design
      • A case control, pharmacy adjudication, prescription fulfillment study design coding prescription fulfillment decisions into the dependent variable nominal categories of filled, switched, delayed, and stopped.
      • Each prescription of each Part D participant within the HMO will be followed monthly throughout 2006 via a Part D health plan’s pharmacy adjudication database.
      • Statistical analysis of the prescription decisions by members over one full year of enrollment. Enrollees (n=500) will be analyzed for the effect of the independent variable, the doughnut hole , for 1 entire year.
      • In addition, a group of enhanced members (n = 250) with doughnut hole coverage will provide a control group for the primary study group (members with standard Medicare PDP benefits - or non-coverage through the doughnut hole ).
      • In compliance with HIPAA regulations, patient information will be blinded. Thus, no patient names will be disclosed in this research ensuring full-protection of human subjects’ health information privacy.
    • Days Spent in the “doughnut hole” Legend: Distribution of Days Spent by Members in the Doughnut Hole The graph displays the distribution of days spent in the doughnut hole by the 500 members of the standard Part D prescription drug plan (standard PDP). The mean was 144.68 days +/- 2.268 SEM.
    • Rx Fulfillment Behaviors Legend: Fulfillment Behaviors for Members Who Experienced the Doughnut Hole This table shows the prescription fulfillment behaviors of standard PDP members. Data are expressed in terms of the frequency, percent, and cumulative percent. Total number of participants n = 500. Legend: Fulfillment Behaviors for Members without a Doughnut Hole This table shows the prescription fulfillment behaviors of enhanced members. Data are expressed in terms of the frequency, percent, and cumulative percent. Total number of participants n = 250. Fulfillment Behaviors for Members Who Experienced the Doughnut Hole Fulfillment Behaviors for Members without a Doughnut Hole 100.0 500 Total 5.6 28 Switched, Stopped, and Delayed 10.0 50 Delayed and Stopped 5.2 26 Switched and Stopped 9.8 49 Switched and Delayed 6.0 30 Stopped 22.0 110 Delayed 13.4 67 Switched 28.0 140 Filled Percent Frequency Doughnut Hole = Y 100.0 250 Total 1.2 3 Switched, Stopped, and Delayed 8.4 21 Delayed and Stopped 4.0 10 Switched and Stopped 3.2 8 Switched and Delayed 8.4 21 Stopped 10.8 27 Delayed 10.0 25 Switched 54.0 135 Filled Percent Frequency Doughnut Hole = N
    • Rx Fulfillment Behaviors – Frequency graphs Legend: Rx Fulfillment Behavior of Standard PDP Members This figure shows the prescription fulfillment behavior of standard PDP members when experiencing the doughnut hole. Data are expressed as the mean of the number of participants who 1 = filled, 2 = switched, 3 =delayed, 4 = stopped, 5 = both switched and delayed, 6 = switched and stopped, 7 = delayed and stopped, or 8 = switched, stopped and delayed their prescription medication. Total number of participants n = 500. Legend: Rx Fulfillment Behavior when NOT Experiencing the Doughnut Hole This figure shows the prescription fulfillment behavior of enhanced members, who do NOT experience the doughnut hole. Data are expressed as the mean of the number of participants who 1 = filled, 2 = switched, 3 =delayed, 4 = stopped, 5 = both switched and delayed, 6 = switched and stopped, 7 = delayed and stopped, or 8 = switched, stopped and delayed their prescription medication. Total number of participants n = 250. Frequency Frequency
    • Percentage of Classes Affected Legend: Percentage of Classes Affected by Prescription Fulfillment Decisions of Standard PDP Members This pie chart shows the percentages for the classes which were impacted by prescription fulfillment behaviors of standard PDP members. Data are percent. Total number of participants n = 500.
    • Odd Ratios Legend: Descriptive Cross Tabulation for Prescription Fulfillment Behaviors and the presence of a doughnut hole with Odds Ratios The above table compares the prescription fulfillment behaviors identified for members experiencing and Not experiencing the doughnut hole . Prescription fulfillment frequencies are displayed for each type of prescription fulfillment behavior possible from a member; these are separated by group (those who experienced the doughnut hole compared with those who did NOT experience the hole. Odd ratios are displayed for each classification of finalized cumulative prescription decisions made by members (p<0.05). 750 750 250 500 Total 4.667 31 3 28 Switched, Stopped, and Delayed 1.190 71 21 50 Delayed and Stopped 1.300 36 10 26 Switched and Stopped 3.063 57 8 49 Switched and Delayed 0.714 51 21 30 Stopped 2.037 137 27 110 Delayed 1.340 92 25 67 Switched 0.519 275 135 140 Filled Rx Fulfillment Behavior No hole exp – had full coverage at all times Yes – Experienced the hole – no coverage Odds Ratio Total Doughnut Hole Y or N   Rx Fulfillment Behavior Cross Tabulation with Odds Ratios
    • Covariate Analysis Legend: Multinomial Regression. This table displays the findings of a multinomial regression model. A stepwise method was used to introduce age, gender, type of class of medications, the number of medications, and days spent in the doughnut hole were reported. Reference category is filled. The odds ratios for each variable are displayed. (p<0.05) - P=.000 Significance of Days Spent in the Hole 1.500 2 6 32 different Medications 1.750 8 28 20 Different Medications 5.667 3 34 16 Different Medications 2.800 5 28 9 Different Medications 1.833 3 11 7 Different Medications Odd Ratios greater than 1.5 times p=.000 Significance of Number of Medications .833 6 10 Other (Skin, Stroke, Dental) (9) .944 36 68 Cancer (8) 1.009 58 117 Gastrointestinal (7) 1.059 51 108 Endocrine & Metabolic (6) 1.196 46 110 Central Nervous System (5) .688 32 44 Cardiovascular (4) 1.308 13 34 Anti-infective (3) .313 8 5 Analgesic (2) - 0 4 Asthma/Allergy (1) p=.712 Significance of Classes of Medication 1.014 141 286 Female .982 109 214 Male p=.848 Significance of Gender .538 13 14 Age 77 .767 15 23 Age 74 p=.355 Significance of Age Odds Ratio No – No hole exp – had full coverage at all times Yes – Experienced the hole, no coverage Multinomial Regression Results (n=750) Variables in the Equation
    • Results
      • Each of the 750 members averages 17.5 different medications +/- .253 SEM encompassing an average of 5.9 classes of medications +/- .058 SEM. (SEM - standard error of the mean)
      • 54 percent of enhanced members chose to fill all of their prescriptions at regular intervals compared to only 28 percent of members experiencing the doughnut hole .
      • The mean distribution of days spent in the doughnut hole by the 500 members of the standard Part D prescription drug plan was 144.68 days +/- 2.268 SEM.
      • Medicaid Part D members who experienced the doughnut hole are 1.3 times more likely to switch, 2 times more likely to delay, 3 times more likely to switch and delay, and 4.7 times more likely to switch, stop, and delay their prescription medications.
      • “ Multi-layering” refers to prescription fulfillment decision making that alters the prescription fulfillment process by means of more than two fulfillment behaviors.
    • Results Continued…
      • 22 percent of the standard PDP members delayed their prescriptions, 13.4 percent switched medications, 10 percent delayed and stopped some medications, and over 9 percent switched and delayed their medications.
      • In comparison, the enhanced group had 10.8 percent delayed prescriptions, while 10 percent of members switched prescriptions.
      • In the standard PDP group, the fulfillment decisions in regards to 1 or more group of medications was altered 70 percent versus 46 percent with the enhanced group.
      • 28.2 percent of doughnut hole members affected one class of medications by making a decision other than filling their prescription.
      • Alarmingly, 43.2 percent of the time standard PDP members’ prescription fulfillment decisions affected two or more classes of therapy.
    • Results Continued…
      • It was also noted that 17 percent of the time, three or more classes were impacted by their prescription fulfillment decisions.
      • In comparison, the enhanced group showed prescription fulfillment decisions impact three or more medication classes 8.8 percent of the time.
      • Multinomial Regression demonstrated that the Number of Different Medications and the Number of Days Spent in the Hole are significant (p=.000; p=.000) contributors to a prescription being switched, delayed, or stopped.
    • Conclusions
      • The doughnut hole is a factor in altering prescription fulfillment decisions by Medicare Part D members.
      • Alternative designs of PDPs, which limit excessive financial burden, may increase patient compliance with medications.
      • Further research is warranted to adequately determine the total heath care costs, as well as clinical outcomes associated with the current Medicare Part D PDP doughnut hole design.
    • ISPOR POSTER
      • INDIVIDUAL’S HEALTH - Health Care Use & Policy Studies 
      • PIH48 RELATIONSHIP BETWEEN DRUG COST COVERAGE AND PRESCRIPTION DECISION MAKING IN MEDICARE PART D ENROLLEES  Hales J1 , Dudley S2, Hegamin A1, Poulios N3, Mills K1 
      • Here is the written response:
      • RELATIONSHIP BETWEEN DRUG COST COVERAGE AND PRESCRIPTION DECISION MAKING IN MEDICARE PART D ENROLLEES for presentation at the ISPOR 14th Annual International Meeting to be held May 16-20, 2009 at the Renaissance Orlando Resort at SeaWorld in Orlando, FL, USA.  Congratulations, your abstract has been accepted as a POSTER PRESENTATION during the following session: POSTER SESSION III Wednesday, May 20, 2009 8:00 AM - 3:00 PM